July 12, 2011 | 1
It’s not unusual to fumble when trying to recall one’s family medical history—especially in the absence of integrated electronic health records (EHRs). But those cumbersome forms and recitations help doctors to predict patients’ risks for disease later in life, especially for partially heritable afflictions, such as breast or colorectal cancers.
However, once the new-patient querying has stopped, many physicians and other health professionals don’t think to check in with patients over the years to see what has changed.
And that might be a mistake, according to a new study published in the July 13 issue of JAMA, The Journal of the American Medical Association. Researchers found that changes in a person’s family cancer landscape can alter screening recommendations significantly—especially for a subset of people between the ages of 30 and 60.
"If a patient’s family history is not updated during early and middle adulthood, the opportunity may be missed to intervene with earlier or more intensive screening that maximizes the likelihood of detecting cancer at an early, treatable stage," noted the authors in their new study.
Based on data from thousands of U.S. adults, the researchers found that 7.2 percent of 30-year-old women would be recommended for early MRI breast cancer screening based on their reported family history. As a patient’s relatives age and are more likely to have had a cancer diagnosis, by the time women reach 50 some 11.4 percent of them would be up for this more intensive screening—in addition to mammograms.
Some 2.1 percent of 30-year-olds would be recommended for early colonoscopy based on family history. And if patients continue to report any new incidences of cancer in the family, by age 50—the earliest age current guidelines recommend seeking colorectal cancer screening for the general population—that number hit 7.1 percent. Although the screening recommendations would change for a slim minority of people, the population-wide impact could add up to be in the millions.
"We hope this new information will help educate physicians to more frequently ask patients these important questions," Sharon Plon, of Baylor College of Medicine and co-author of the new study, said in a prepared statement. She and her colleagues suggest that doctors check in with patients every five to 10 years to see if there are any changes in immediate blood relatives’ medical history.
Not all of this data responsibility need fall on the physicians. "Patients should be aware which of their close relatives have had cancer, the location or organ where the cancer started, and the age at which the relative was first diagnosed with cancer," Dianne Finkelstein, of the Massachusetts General Hospital Biostatistics Center and co-author of the paper, said in a prepared statement.
Once electronic health records become more the norm, "there is tremendous potential to ensure that people at higher risk of cancer are being screened earlier and using the best methods," Plon said. And if record systems can share data among one another, family members might be able to sign off on a function "to have their diagnoses (and other information, such as test results) automatically populate family history sections in the EHRs of specified relatives," Louise Acheson, of Case Western Reserve University School of Medicine, pointed out in an essay published in the same issue of JAMA. Such an automated link would cut down on the amount of uncertainty and any reticence on the part of patients who would otherwise have to self-report all of the family info to doctors via forms or verbally.
Acheson also notes that "although primary care clinicians generally order cancer screening," specialists would also be better off knowing more about a patient’s cancer risks, so that they could keep a closer eye out for early-warning signs.
Family history has long been considered an important predictor of cancer risk, especially when the age of diagnosis is known, but its precise place in the diagnostic field is still in limbo. And more screening often also brings higher initial costs—and more false positives, which can be stressful and sometimes even dangerous misdiagnoses. By Acheson’s calculations, if the new study’s increases in colorectal cancer screening were instituted, an extra 1.7 million people would get colonoscopies each year.
As unpleasant as the short-term changes might be to those who enter a new cancer risk category based on their family’s record, the additional screening could save more lives. And if higher-risk folks are filtered out of the population averages, it might mean screening recommendations could decrease for those who don’t fall into these categories. And that would likely be good news for both payers and patients.
Image courtesy of iStockphoto/crysrob